Reproducibility of the interpretation of hysterosalpingography in the diagnosis of tubal pathology

The aim of the study was to estimate the inter- and intra-observerreproducibility of the interpretation of hystero-salpingography(HSG) in the diagnosis of tubal pathology, and associate reproducibilitywith diagnostic accuracy. Four observers evaluated 143 HSGstwice, on proximal tubal obstruction, distal tubal obstruction,hydrosalpinx and peritubal adhesions. Diagnostic laparoscopywith chro-mopertubation was considered to be the reference strategy.Reproducibility (inter- and intra-observer agreement) was expressedin terms of K-values. Accuracy was expressed in terms of sensitivity,specificity and likelihood ratios. K-values for reproducibilitybetween observers were almost perfect for proximal obstruction,substantial for distal obstruction and hydrosalpinx, and moderatefor adhesions. K-values for reproducibility within observerswere almost perfect for proximal obstruction and substantialfor distal obstruction, hydrosalpinx and adhesions. HSG hada high specificity for proximal obstruction, but a low sensitivity.Distal obstruction, absence of hydrosalpinx and adhesions hada poor accuracy. The likelihood ratio for the presence of hydrosalpinxwas high. In conclusion, proximal tuba! obstruction detectedon HSG changes the pre-test probability of proximal tubal obstructionfrom 16 to 50%. Proximal tubal patency detected on HSG changesthe pre-test probability of proximal tubal patency from 16 to9%. It is unlikely that a lack of reproducibility of the interpretationof proximal tuba! patency is responsible for the low sensitivity;alternative explanations are artefacts occurring while performingHSG or an imperfect reference strategy diagnostic laparoscopy.HSG is of limited use in diagnosing distal tubal obstructionand hydrosalpinx, and has no value in the detection of peritubaladhesions.     

Association of ambient air‐pollution levels with acute asthma exacerbation among children in Singapore

BACKGROUND: Air-pollution levels have been shown to be associated with increased morbidity of respiratory diseases. METHODS: Data for ambient air-pollutant levels, meteorologic factors, and hospitalization or emergency room (ER) visits for acute asthma in Singapore children over a 5-year period (1990-4) were obtained and analyzed for associations by time-series methods. RESULTS: Throughout this period, the annual mean and 24-h mean levels for sulfur dioxide (SO2), nitrogen dioxide (NO2), and total suspended particles (TSP) and maximum 1-h daily average for ozone were generally within the air-quality guidelines established by the World Health Organization (WHO). However, positive correlation between levels of each of these pollutants and daily ER visits for asthma was observed in children aged 3-12 years, but not among adolescents and young adults (13-21 years old). The association with SO2 and TSP persisted after standardization for meteorologic and temporal variables. An adjusted increase in 2.9 ER visits for every 20 microg/m3 increase in atmospheric SO2 levels, lagged by 1 day, was observed on days when levels were above 68 microg/m3. With TSP, an adjusted increase of 5.80 ER visits for every 20 microg/m3 increase in its daily atmospheric levels, lagged by 1 day, was observed on days with levels above 73 microg/m3. Similar results were also obtained after controlling for autocorrelation by time-series analysis. CONCLUSIONS: These associations were observed even though the overall levels of all pollutants were generally within the air-quality guidelines established by the WHO. These findings suggest that asthmatic children are susceptible to increased levels of air pollutants, particularly SO2 and TSP, although the ambient levels are generally within "acceptable" ranges.     

Relatives’ perspectives on the quality of care in an Intensive Care Unit: The theoretical concept of a new tool

Objective

To examine the potential of a questionnaire (CQI ‘R-ICU’) to measure the quality of care from the perspective of relatives in the Intensive Care Unit (ICU).

Methods

A quantitative survey study has been undertaken to explore the psychometric properties of the instrument, which was sent to 282 relatives of ICU patients from the Erasmus MC, an academic hospital in Rotterdam, the Netherlands. Factor-analyses were performed to explore the underlying theoretical structure.

Results

Survey data from 211 relatives (response rate 78%) were used for the analysis. The overall reliability of the questionnaire was sufficiently high; two of the four underlying factors, namely ‘Communication’ and ‘Involvement’, were significant predictors. Two specific aspects of care that needed the most improvement were missing information about meals and offering an ICU diary. There is a significant difference in mean communication with nurses among the four wards in Erasmus MC.

Conclusions

The CQI ‘R-ICU’ seems to be a valid, reliable and usable instrument. The theoretical fundament appears to be related to communication.

Practice implications

The newly developed instrument can be used to provide feedback to health care professionals and policy makers in order to evaluate quality improvement projects with regard to relatives in the ICU.     

Microduplication of 15q13.3 and Xq21.31 in a family with tourette syndrome and comorbidities

Tourette syndrome (TS) is a childhood onset neurodevelopmental disorder. Although it is widely accepted that genetic factors play a significant role in TS pathogenesis the etiology of this disorder is largely unknown. Identification of rare copy number variations (CNVs) as susceptibility factors in several neuropsychiatric disorders such as attention deficit‐hyperactivity disorder (ADHD), autism and schizophrenia, suggests involvement of these rare structural changes also in TS etiology. In a male patient with TS, ADHD, and OCD (obsessive compulsive disorder) we identified two microduplications (at 15q13.3 and Xq21.31) inherited from a mother with subclinical ADHD. The 15q duplication included the CHRNA7 gene; while two genes, PABPC5 and PCDH11X, were within the Xq duplication. The Xq21.31 duplication was present in three brothers with TS including the proband, but not in an unaffected brother, whereas the 15q duplication was present only in the proband and his mother. The structural variations observed in this family may contribute to the observed symptoms, but further studies are necessary to investigate the possible involvement of the described variations in the TS etiology. © 2013 Wiley Periodicals, Inc.     

Modeling energy expenditure associated with isometric, concentric, and eccentric muscle action at the knee

This study was designed to derive and test a model of energy expenditure (dE/dt) during different modes of human muscle actionin vivo dE/dt for the quadriceps muscle was expressed as: dE_quad/dt=K1(ω)+K2(Tiso)+dW/dt, where K1 and K2 are constants, (ω) is joint angular velocity (^o/sec), (Tiso) represents the knee extension torque that could be developed by the active muscle if the muscle action were isometric (N-m), and (dW/dt) is the rate of work performed (W). Volunteers performed a series of repetitive 2- to 4-min knee extension exercises, while varying either the knee extension torque or velocity. The average joint torque, angular velocity, rate of work performed, and net energy expenditure (E) above resting and dE/dt were determined for each muscle action. The best fit values for K1 and K2 for concentric, eccentric, and isometric muscle actions were 0.044, −0.55, and 0 W/^c/sec, and 4.14, 5.28, and 2.17 W/N-m, respectively. The coefficients of determination (r ²) for the model predictions of dE_quad/dt for the three modes of muscle action were 0.78, 0.71, and 0.71, respectively. The correlation coefficient between predicted and experimental dE/dt for all modes of muscle action combined was 0.93. These findings indicate the model provides a useful tool for predicting the rate of energy expenditure associated with cyclic knee extension efforts.     

The accuracy of multivariate models predicting ovarian reserve and pregnancy after in vitro fertilization: a meta-analysis

BACKGROUND: To review the accuracy of multivariate models for the predictionof ovarian reserve and pregnancy in women undergoing IVF comparedwith the antral follicle count (AFC) as single test. METHODS: We performed a computerized MEDLINE and EMBASE search to identifyarticles published on multivariate models for ovarian reservetesting in patients undergoing IVF. In order to be selected,articles had to contain data on the outcome of IVF in termsof either pregnancy and/or poor response and on the predictionof these events based on a multivariate model. For the selectedstudies, sensitivity and specificity of the test in the predictionof poor ovarian response and non-pregnancy were calculated.Overall performance was assessed by estimating a summary receiveroperating characteristic (ROC) curve, which was compared withthe ROC curve for the AFC as the current best single test. RESULTS: We identified 11 studies reporting on the predictive capacityof multivariate models in ovarian reserve testing. All studiesreported on the prediction of poor ovarian response, whereasnone reported on the occurrence of pregnancy. The sensitivityfor prediction of poor ovarian response varied between 39% and97% and the specificity between 50% and 96%. Logistic regressionanalysis indicated that cohort studies provided a significantlybetter discriminative performance than case–control studies.As cohort studies are superior to case–control studies,further analysis was limited to the cohort studies. For thecohort studies, a summary ROC curve could be estimated, whichhad a shape similar to that previously made for the AFC. CONCLUSIONS: The accuracy of multivariate models for the prediction of ovarianresponse in women undergoing IVF is similar to the accuracyof AFC. No data are available on the capacity of these modelsto predict pregnancy, let alone live birth. On the basis ofthese findings, the use of more than one single test for theassessment of ovarian reserve cannot currently be supported.     

Platelet binding to monocytes increases the adhesive properties of monocytes by up-regulating the expression and functionality of beta1 and beta2 integrins

Human monocytes adhere to activated platelets, resulting in the formation of platelet-monocyte complexes (PMC). Complex formation depends on the interaction between platelet-displayed P-selectin and the specific ligand for P-selectin on leukocytes, P-selectin glycoprotein ligand-1 (PSGL-1). We have recently shown that monocytes within PMC have increased adhesive capacity to the activated endothelium. To better understand the effect of platelet binding on the capacity of monocytes to adhere to activated endothelium, the P-selectin-PSGL-1 interaction-induced changes in integrin functionality were studied. The binding of platelets to monocytes via P-selectin-PSGL-1 interactions was shown to increase expression and activity of alpha4beta1 and alphaMbeta2integrin, with a concomitant decrease in L-selectin expression. Furthermore, the binding of platelets to monocytes resulted in increased monocyte adhesion to intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and fibronectin. Platelet binding was also responsible for an increase in monocyte transendothelial migration. Similar effects were observed after engagement of PSGL-1 with specific antibodies or with P-selectin immunoglobulin protein. Our data suggest that platelets, by binding via P-selectin to PSGL-1 on monocytes, induce up-regulation and activation of beta1 and beta2integrins and increased adhesion of monocytes to activated endothelium. Hence, monocytes within PMC are in a higher state of activation and may have, therefore, an increased atherogenic capacity.